Letter to the editor: Recovery and outcomes of patients denied early liver transplantation for severe alcohol‐associated hepatitis
Authors: Anees Ahmad
Journal: Hepatology (2022)

To the editor, We read the article "Recovery and Outcomes of Patients Denied Early Liver Transplantation for Severe Alcohol‐Associated Hepatitis" by Musto et al. with great interest.[1] We enjoyed reading the concisely written article and commend the authors on their outstanding efforts. Numerous scenarios have been described concisely by the authors. The article's main point is that spontaneous recovery from alcohol‐associated hepatitis following liver transplant evaluation is associated with younger age, a lower international normalized ratio index, and lower peak model for end‐stage liver disease (MELD) scores. Relapse to alcohol use is the most common cause of impaired postrecovery survival; however, among all survivors of alcohol‐associated hepatitis, only liver transplantation was associated with improved survival. However, it seemed worthwhile to add a few more points to improve the article's conclusion. To begin, major concerns about the study's accuracy arise as a result of the small sample size, which determines the study's power. Furthermore, the median age of the patients was 45.5 years, and 68.1% of the patients were male, raising various concerns about the validity of the findings. To illustrate, a 2018 study by Sundaram et al.[2] enrolled twice the population of this study, resulting in statistically significant outcomes. Additionally, after excluding patients with concurrent chronic liver diseases and alcohol‐associated cirrhosis, only those with severe alcohol‐associated hepatitis were identified. Even though patients were evaluated using conventional scoring systems such as the MELD score, the authors forgot to acknowledge other major evaluation tools. For example, patients with severe alcohol‐associated hepatitis who required corticosteroid treatment were identified based on Maddrey's discriminant function score >32. This tool suggests that patients with alcohol‐associated hepatitis may have a poor prognosis and would benefit from steroid administration, which could have resulted in a more effective treatment plan.[2] Other significant barriers to transplantation in this population were not detailed, including a lack of insight into addiction, social isolation (lack of employment, no spouse or companion, and no fixed abode), and comorbid psychiatric conditions, such as uncontrolled polysubstance use or unstable personality disorder, as well as a history of numerous failed rehabilitation attempts.[3] When an patient who misuses alcohol resumes drinking, it is discouraging for transplant coordinators, social workers, and nurses. Medical justifications for refusing liver transplantation were also ignored. Choi et al.[4] elaborated in a 2022 study that pancreatitis, acute respiratory distress syndrome, and hepatocellular carcinoma tumor burden were all significant factors. Alcohol‐related liver disease presents and progresses in a complex and heterogeneous manner. Transplant providers struggle to quantify an often‐subjective set of data, all the more so given the difficulty of determining psychosocial factors and their dynamic nature.[4] However, the reasons for the denial of liver transplant have received less attention. As a result, the transplant community has struggled to identify and care for these patients. CONFLICT OF INTEREST Nothing to report.